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MACRA and Quality Payment Program

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 eliminated the much-maligned sustainable growth rate (SGR) payment formula for Medicare and replaced it with the Quality Payment Program. The updated program includes two paths for physician reimbursement:

The Merit-based Incentive Payment System (MIPS)
Alternative Payment Models (APMs)*

*There are two types of APMs: Advanced and non-Advanced

Under MIPS, payment adjustments ended for:

The Physician Quality Reporting System (PQRS)
The Value-based Payment Modifier (VM)
The Medicare and Medicaid Electronic Health Record (EHR) Incentive Program

However, key components of these discontinued programs were consolidated and carried forward into MIPS.

There are four distinct areas of the MIPS of which providers should be aware.

In 2021, the MIPS program will make up to positive or negative 7 percent adjustments to a physician’s payment based on a composite score of their performance in 2019 across the four new performance categories.

In contrast, physicians who qualify to participate in an Advanced APM are exempt from MIPS and are eligible for a five percent lump sum bonus payment on Medicare Part B services from 2019–2024, and will receive higher annual increases in their payments starting in 2026 and onward.

Participants in an Advanced APM must:

Take on more than nominal risk (or be part of a medical home)
Report quality measures comparable to those adopted under MIPS
Use certified EHR technology

Only risk-bearing ACOs, patient-centered medical homes, and certain bundled payment models qualify as Advanced APMs. Physicians participating in non-Advanced APMs are subject to MIPS and are ineligible for the five percent lump sum bonus payment.